Mental Health and Aging

Introduction

Mental health is a key element of overall health and well-being in older adulthood. Individuals with mental health needs face significant impacts on daily functioning, socialization, meaningful relationships, and health and safety. While not a normal part of aging, in 2012 roughly 16% of Americans aged 50 or over experienced mental health concerns within the year. In fact, this estimate may be low, as research consistently documents the challenges of obtaining accurate measures of mental health in older adults due to underdiagnosis, varied definitions of the terms "mental health" and "older adult," and different sampling methods for individuals living in the community compared to those who are homeless or living in nursing home settings. Given the growing number of older adults and service systems unprepared to meet their mental health needs, there are many opportunities for grantmakers to support programs and efforts that will enhance lives and improve access to quality care.

What is unique about mental health in older adults?

In older adulthood a variety of losses (for example, changes in roles, living arrangements, ability to perform certain activities, deaths of loved ones), chronic illnesses, cognitive, functional and sensory impairments as well as physiological changes of normal aging directly influence the risk of developing a mental health condition as well as the course of that condition. While these circumstances can occur at any time during a person's life, they are more likely both to occur and to be a consistent presence in the life of an older adult. If the older adult is not able to cope effectively with the cumulative effects of these stressors, mental health concerns may be triggered or perpetuated.

In addition, the complex interaction between age-related circumstances and mental health symptoms frequently complicates accurate identification, diagnosis, and treatment in older adulthood. The impacts of these circumstances often mimic formal mental health diagnoses that need treatment and vice versa. For example, in an older adult with multiple losses, it may be difficult to determine if his or her reactions are normative grief or depression. Memory problems may be a result of depression, early signs of dementia, or complications from medical conditions or medication side effects. Isolation and withdrawal from usual activities may be due to depression, dementia, physical impairments, or hearing loss.

Certain health conditions—for example, cardiac disease, Parkinson's disease, and diabetes—often correlate with depression. Or perhaps due to physiological changes in how medications are metabolized, medication interactions may trigger symptoms that look like depression. These confusing overlays, especially when coupled with ageist stereotypes, complicate assessment and care planning. In fact, studies show that 40-90% of older adult mental health concerns are not detected in primary care, the setting where the majority of individuals, regardless of age, obtain mental health treatment. Therefore consumer and provider education about the unique factors of mental health and aging is essential.

Lifetime exposure to, and experiences with, mental health issues are also unique in older adults. Individuals may be experiencing mental health needs for the first time or may be entering older adulthood with a life-long history of symptoms. Older adults with a history of mental health needs will carry the physical and psychosocial impacts of their condition as well as their experiences (or lack thereof) with various treatments and service systems. Cohort issues are also at play. The current cohort of older adults lived during various eras of mental health perception and treatment in America. Their experiences range from significant mental health stigma and treatments that often correlated with negative side effects or institutionalization to more open acknowledgement of mental health needs, active use of various substances, and psychotherapy as a normative experience. This cohort effect impacts how older adults self-identify, experience, and describe their emotions; many of the "middle old" and "oldest old" older adults express emotional distress through physical symptoms or vague complaints that are not properly identified by professionals as mental health issues. Across the current and increasingly diverse population of older adults, cohort effects also impact outreach, education, assessment, and engagement strategies as well as treatment expectations.

While not the majority of older adults, those who experience mental health issues face serious consequences in multiple domains of life. Research shows that older adults with mental health issues experience consistent negative impacts, including emotional distress, strained social relationships and isolation, and decreased quality of life. They also experience increased complexity and number of medical conditions, disability and impairment, outpatient, emergency department and inpatient health care utilization, caregiver stress, mortality, and risk of suicide. Therefore identification and treatment of mental health issues stands to improve older adults’ lives in many ways.

In addition to these direct negative consequences for the older adult, mental health and aging also has implications for the healthcare system. For example, compared to older adults without depression, those with depression had nearly twice the number of outpatient visits and when hospitalized, had twice the number of inpatient days over the anticipated discharge date. Individuals with symptoms of depression also represented 75% of patients who overutilize primary care services. In the current healthcare environment focused on improving quality, improving population health, and decreasing cost, investment in improved identification and treatment of older adults' mental health issues can have impact on both individual and systemic levels.

Defining mental health

Older adults face a variety of mental health concerns, including depression, anxiety, substance use, trauma, serious mental illness, personality disorders, and dementia. Hoarding is also a significant concern garnering increasing attention. This issue brief excludes dementia, as its behavioral and psychiatric complexity, impact, and increasing frequency merit a focused issue brief. When considering the mental health needs of older adults, it is important to acknowledge that mental health conditions often occur with each other. The Institute of Medicine's comprehensive 2012 review estimates that 6.8-10.2% of people 65 years or older have one or more mental health conditions, with 2.0-2.4% having two or more and 0.5-0.8% with three or more. Therefore grantmakers may be interested in programs that address a specific diagnosis, a combination of diagnoses, or "mental health" in general, though it would be advisable to obtain a clear definition of this term from applicants.

To be formally diagnosed with a mental health condition, an individual must experience a constellation of symptoms that impact day-to-day functioning over discreet periods of time. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) details conditions and diagnostic criteria. A brief overview will enhance grantmakers' understanding of common conditions impacting older adults.

Treatment

Literature suggests that older adults hold contradictory views on mental health treatment. Though 80-90% are open to seeking help for mental health concerns and believe treatment will help, roughly a quarter to a third of older adults believe these conditions are best handled alone or will go away with time. Many older adults with mental health conditions do not perceive that they need treatment or actively choose not to pursue it. In addition, research consistently finds that compared to younger adults, older adults with mental health needs are less likely to obtain treatment in general, but especially from mental health specialty programs. Factors influencing this underutilization include stigma, not knowing where to go for help, concerns about cost, and professionals not identifying mental health concerns. When treatment is obtained, it tends to be via medication through a primary care physician or services from community-based agencies.

Despite these utilization trends, it is estimated that in 2009, services and medications for mental health disorders in Americans age 65 and older cost $17.1 billion, setting mental health within the top ten most costly conditions for this age group. Just over half (52.5%) of the costs were paid by Medicare, with out-of-pocket (18.3%), private insurance (11.7%), Medicaid (11.4%), and other sources (6.1%) covering the balance. Various federal policy changes in recent years have improved Medicare and other insurance coverage of mental health screenings and treatment. However, limitations still exist and simultaneous cuts in state and local budgets have caused many providers to reduce or eliminate services. This formal reimbursement landscape results in many gaps that grantmakers can fill at both program and advocacy levels.

As with younger populations, the majority of mental health concerns can be effectively treated in older adults. A combination of prescription medication and psychotherapy (also known as talk therapy) remains ideal treatment, but the use of medication has increased over time while psychotherapy has decreased. Regardless, a substantial evidence base shows the effectiveness of psychotherapy with older adults, particularly cognitive behavioral therapy, interpersonal psychotherapy, and problem-solving therapy approaches. Individual psychotherapy typically is billed to insurance or, with less frequency, paid entirely out-of-pocket. Like outpatient medical care, Medicare covers 80% of its agreed-to fee for contracted psychologists and licensed clinical social workers. Telephonic treatment is not covered and as discussed, an individual must meet diagnostic criteria for a mental health condition. Medicaid coverage varies by state, treatment setting, and provider type.

Individual psychotherapy is offered in a variety of settings ranging from private practices to community-based services to professionals integrated in primary care. Psychotherapy is also offered as part of broader, structured programs that can be implemented by a variety of professionals in community-based or medical settings. These programs typically have mixed funding sources, including grant funding. The following are well-researched evidence-based programs that include psychotherapy:

Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) is a primary care, team-based program that includes psychotherapy and rigorous symptom monitoring via a care manager for older adults with depression. It is a long-term intervention, lasting several months or over one year. IMPACT has received extensive support from the John A. Hartford Foundation (NY).

Program to Encourage Active and Rewarding Lives (PEARLS, formerly Program for Encouraging Active Rewarding Lives for Seniors) is an in-home, team-based program that includes psychotherapy for physically-impaired, isolated older adults with varying degrees of depression. It is designed to integrate into typical community-based case management activities and last roughly six months. The Archstone Foundation (CA) awarded a grant to The LGBT Community Center of the Desert in Palm Springs, CA to integrate PEARLS into their low-cost counseling clinic that serves LGBT older adults. In addition to counseling individuals, the grant supported training on this model to interns and outreach to other health providers and older LGBT adults.

As discussed, identification of mental health conditions and consumer education are also significant areas of need. While Medicare now covers depression and substance use screenings in primary care, screenings in other settings or for other mental health conditions typically cannot be reimbursed by insurance. Consumer education and outreach are largely unfunded areas and many programs turn to grants to support or supplement limited funds from federal and state sources. The following evidence-based programs focus on screening and identification, with behavioral activities that can improve symptoms without formalized psychotherapy or motivate the older adult to pursue formalized treatment:

Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) integrates depression screening, education, simple behavioral change activities, and coordination across service systems into long-term community-based care management services for chronically ill older adults. Services are provided both in-home as well as by telephone over the course of three to six months. Professionals offering the intervention do not need to have formalized mental health training, though such prior experience is helpful. The Grotta Fund for Senior Care of New Jersey has funded several organizations to implement Healthy IDEAS and help manage depression in older adults, including low-income and Latino elders.

Screening Brief Intervention and Referral to Treatment (SBIRT) is a method for substance use screening, education to prevent problem use and abuse, and connection to formalized treatment for individuals using at abuse or dependence levels. Because it is not formal treatment, the method is highly flexible and can be offered in all service settings by any level of professional, though those with mental health training will more quickly be able to implement the method. While models vary, SBIRT interventions can be as short as a one-time, 15-45 minute session. An SBIRT model created specifically for older adults is available and was utilized in the Brief Intervention and Treatment for Elders (BRITE) program.

The majority of older adults obtain mental health treatment via medical primary care practices. Though dated, research has found that among older adults, 50-75% of all primary care visits focus on a mental health issue, yet these concerns also often go undetected in this setting. There are numerous past and present efforts to increase the integration of older adult mental health screenings and access to treatment via primary care, especially in light of the Affordable Care Act. Now more than ever, it is critical to bolster primary care professionals' ability to screen, diagnose, and connect patients with appropriate mental health treatment. This will also require increased capacity of primary care to collaborate with community-based providers in the mental health, substance use, and aging systems.

The two most widely known primary care-based programs with evidence as to their effectiveness are IMPACT and Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Like IMPACT, PROSPECT also utilizes depression care managers as part of team-based primary care and includes both medication and psychotherapy interventions. Lasting 24 months, it is a lengthy intervention and has not been replicated or disseminated as widely as IMPACT. There is significant potential to develop and research additional models of primary care based programs for mental health in older adults given the length of current interventions and their exclusive focus on depression.

Clearly there is a strong evidence base for a variety of screening and treatment programs for the mental health needs of older adults, particularly regarding depression. Unfortunately, research consistently shows a limited number of specially trained providers to execute them. While providers with a variety of education levels offer mental health treatment, many are not familiar with aging issues. Similarly, many professionals in the field of aging are not familiar enough with mental health issues, especially substance use. When one considers the intersection of mental health and aging, the typical specialty providers are psychiatrists, psychologists, and social workers. As of 2010, there were only 1,382 board-certified geriatric psychiatrists in the United States. In 2008, 4.2% of licensed psychologists surveyed by the American Psychological Association indicated geropsychology as their focus. And a 2006 study showed that only 9% of social workers report aging as their primary area of focus, despite the fact that nearly 78% indicate they work with older adults. Because of less-than-ideal reimbursement rates, many mental health providers do not accept Medicare, adding to the shortage of available professionals and disincentivizing professionals to pursue mental health and aging. In addition, specialty training programs and certifications across all disciplines are limited or underutilized. Awareness raising, training and advocacy for improved reimbursements and tuition/loan programs are needed for both students and practicing professionals to build the workforce necessary to meet current and future demands for competent care.

Role of Philanthropy

The John A. Hartford Foundation in New York City has been very active in supporting mental health and aging initiatives over the years. In particular, it has supported training for geropsychiatric nurses and social workers, and funded Centers of Excellence in Geriatric Psychiatry. It also supported the IMPACT program described above, which aims to enhance the care of older people with depression.

The Retirement Research Foundation (RRF) in Chicago has been involved in grantmaking around mental health and aging for many years. Much of this work is focused on ensuring that mental health programs are delivered in culturally competent ways and reach vulnerable older adults who may otherwise fall through the cracks. RRF has funded a number of grants aimed at replicating evidence-based programs to address depression and anxiety among older adults. It also supported the development of the BRIGHTEN Program (Bridging Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking), a patient-centered depression and anxiety assessment and treatment program that relies on a “virtual” interprofessional team and treatment planning. Other RRF-funded projects have related to substance abuse treatment and training programs for allied health professionals (particularly occupational therapists) on mental health issues affecting the older population.

In 2011, the Archstone Foundation (CA) directed over $800,000 in funding toward an initiative on Expanding Mental Health Services. Nine organizations in Southern California were awarded grants to expand mental health service programs by identifying and treating depression in community-dwelling older adults.

In addition to its grants on aging issues, the Daniels Fund of Colorado provides funding to nonprofit organizations that assist youth and adults with alcohol and substance abuse challenges to achieve and maintain stability in their lives through prevention, treatment, or supportive/after-care services.

The Fan Fox and Leslie R. Samuels Foundation of New York recently awarded a grant to Cornell University-Weill Medical College for “Mental Health Needs Assessment and Services for Elderly Crime Victims.” This project will integrate psychosocial evaluations and mental health interventions into elder abuse services.

Trending topics

Any investment in older adult mental health stands to have meaningful impact on the lives of older adults and how professionals understand mental health needs, trends, and service provision. Three issues discussed above—substance abuse, trauma, and development of a trained workforce in mental health and aging—are prime areas where grantmakers can make a substantial contribution. Other issues that are emerging as significant in the field of mental health and older adults are:

Resources

Databases and Resources

National Council on Aging (NCOA) Center for Healthy Aging, Behavioral Health Tools and Resources: Offers links to webinars, fact sheets, issue briefs and other helpful tools grantmakers and providers can use to better understand key issues in mental health and aging as well as evidence-based programs, funding issues, and sustainability lessons from previous programs.

Get Connected! Toolkit (2013 revision): A comprehensive guide to providing health promotion and education activities to prevent substance use and mental health disorders in older adults. Includes a variety of handouts, curricula, and other tools. From SAMHSA, in partnership with NCOA, supported by the Administration on Aging.

GeroCentral: Intended for psychology providers to access information regarding mental health and aging, the site offers excellent brief overviews of mental health conditions, treatments, and treatment settings, many written by leading clinicians. Policy, advocacy, research, professional training, and funding issues are also reviewed. While content is targeted to psychologists, information is applicable to any professional or grantmaker. A collaboration of the American Psychological Association, the Council of Professional Geropsychology Training Programs, and Psychologists in Long Term Care.

“Silver and Blue: The Unfinished Business of Mental Health Care for Older Adults,” a national poll conducted by The John A. Hartford Foundaiton. The poll's findings found that a large number of older Americans with depression, anxiety, or other mental health disorders are receiving treatment that does not meet evidence-based standards, and many do not know that depression can put their health at increased risk. A complete list of findings, including care preferences, shortcomings in care, reasons for stopping treatment, stigma, and misconceptions are available.

Issue Briefs and Reports

National Council on Aging Center for Healthy Aging, Behavioral Health Tools and Resources Issue Briefs (2012): A one-stop, online location for a series of 13 issue briefs focusing on clinical, program, policy, and funding issues in mental health and aging.

Institute of Medicine, The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? (2012): "Report at a Glance" section contains summary documents focused on workforce issues but also offers basic information about mental health and aging. "Get this Report" section allows free download or hard-copy purchase of an excellent, in-depth exploration of many topics related to mental health and aging in addition to workforce needs and development. Comprehensively researched, a must-read for individuals seeking detailed information about mental health and aging.

Mentally Healthy Aging: A Report on Overcoming Stigma for Older Americans (2005):
Documents the results from two roundtables (held in 2003 and 2004 by SAMHSA) for professionals and consumers regarding mental health, aging, and stigma. Helpful as long as the reader bears in mind that statistics and references presented are dated. However, much of the content and recommendations still apply to areas of need in the field.

Substance Abuse and Mental Health Services Administration
In particular, click on Publications and use Advanced Search tool to enter "Older adults” as population for practitioner guides, research summary reports, and consumer education pamphlets regarding mental health, substance use, and aging.

The Older Americans Substance Abuse and Mental Health Technical Assistance Center was formerly available via SAMHSA, but has been disabled. Many of its publications are available using the search instructions provided above or via the Administration for Community Living. Last updated in 2009, an archive of the Center's work and publications exists.